Background and Purpose: South Africa has the largest public antiretroviral (ART) service in the world but until recently it was unable to report from primary sources the numbers of patients on ART and was unable to monitor the program outcomes using routine data. In December 2010 the South Africa National Department of Health adopted a standardized ART monitoring strategy referred to as the 3-Tiered Strategy. The System provides facilities with different options for cohort monitoring based on the resources and infrastructure available. The technical design of the three tiers is pragmatic and appropriate to the facility-level context. The process to implement the System was articulated through an implementation plan. The health management information system was aligned to collate data produced by the System and standard operating procedures were produced to guide system use. Methods: The study comprised a mixed-methods approach to evaluate the implementation of the system in accordance with the implementation plan. Program data were analysed, program documents were reviewed and key informants were interviewed in order to capture the complex and multidimensional nature of the countrywide implementation activities. Results: By October 2014 full implementation had been achieved in 2,139 ART facilities, of a total 3,772 facilities that report ART data. And, of facilities that had reached full implementation, 87% of facilities had submitted data. At the time of analysis, the outcome data available were representative of 55% of active patients on ART. Qualitative results elicited facility-level challenges as well as structural barriers to effective implementation. The study demonstrated that South Africa's introduction of the 3-Tiered Strategy for ART monitoring was championed by senior management in the NDOH who fostered a collaborative environment and structured implementation approach which resulted in wide-scale uptake of the recommended systems, predominantly the electronic register. Conclusions: The implementation of a basics first health information system has yielded a complete set of enrolment and retention on ART data; however there are systemic and structural barriers to the sustainable production of these and additional cohort outcome data. The study has brought attention to the organizational restructuring and the holistic health system interventions required to implement such a system.

By 2005, an estimated 500 000 people with HIV had initiated highly active antiretroviral therapy (HAART) in sub-Saharan Africa. However, disproportionately more women than men have accessed HAART in most developing countries including South Africa. While there has been considerable recent interest in the determinants of mortality among patients receiving HAART in developing countries, there is conflicting evidence about gender differences and survival in HAAR T programmes. This study explored whether there were gender differences in early mortality among 2 843 treatment-naive men and women entering care in a large South African HAART programme. The study was a secondary analysis of patient records covering three time periods: person-time from programme entry to the initiation ofHAART; person-time from HAART initiation to one year on treatment; and the total person-time from programme entry to one year on HAART. Cox' s proportional hazards regression ·was used to investigate crude and adjusted associations between basehne characteristics and mortality as we11 as loss-to-follow-up (LTFU). Using the Sobel test, the study explored whether the degree of disease ( according to CD4 count and WHO stage) played a mediating role in any association between gender and mortality. In all three time periods, the analysis found a strong crude associ~tiol). between male gender and mortality. Prior to HAART-initiation, there was a 31 % increase in the risk of mortality (crude Hazard Ratio (HR) 1.31, 95% CI, 0.93- 1.86; p=0. 131). In the period on HAART, this association strengthened (crude HR 1.57, 95% CI, 1.14-2.16; p=0.005). Overall, male gender increased the risk of mortality in the total cohort by 49% (crude HR, 1.49, 95% CI, 1.17-1.88 ; p=001). Adjustment for baseline characteristics, including CD4 count and WHO stage, attenuated these crude associations. After adjustment, there was no increase in risk associated with male gender in the period pre-HAART (HR 1.01, 95% CI, 0.67-1.51). On HAART, there was a 19% increase in risk (HR 1.19, 95% CI, 0.88-1.67). In the total cohort, this was slightly attenuated (HR 1.15, 95% CI, 0.93-1.50). There was evidence of mediation by degree of disease. In the preHAART period, the Sobel test found significant associations between mortality and CD4 count (p=0.044) as well as WHO stage (p=0.003). On HAART, too, CD4 count (p=0.045) and WHO stage (p< 0.001) appeared to mediate the effect of gender on death. Similarly, in the total cohort, there was evidence to support mediation by CD4 count (p=0.035) and WHO stage (p<0.001). There was a crude association between male gender and the risk of being L TFU (HR for L TFU during the total study period comparing males to females, 1.26, 95% CI, 0.89-1.78 ; p=0.194). This was strengthened by adjustment for age and monthly income (HR,1.35, 95% CI, 0.92-1.97). In this cohort, men appeared to have worse survival prospects than women due to more advanced HIV disease on programme entry. Previous studies have attributed the disproportionate access of women to HAART to gender differences in health seeking behaviour. This study argues that the prime obstacle might be the existing orientation of primary health care systems in developing countries towards the needs of women more than those of men. It suggests that women have better access to primary health services through the existing focus on maternal and child health. Women who are diagnosed and referred for HAART through these services are generally younger and healthier than men, who are diagnosed through services for tuberculosis (TB) and sexually transmitted infections (STis). This might explain why fewer men than women access HAART, and why they are diagnosed at later stages of disease progression. As a result, men may be disadvantaged in access to HAAR T in South Africa. The study suggests a number of short- and long-term solutions including : further research on obstacles to male access to HAART; changes in national policy; and the establishment of male-friendly services as an entry point for men into broader health services. Such approaches might facilitate the earlier diagnosis and treatment of men and improve their survival in HAART programmes.

Background: While several studies have studied the associations between biological factors such as HIV-status with TB transmission or clustering, our understanding of the associations between TB transmission and socio-economic risk factors for TB remains incomplete. More studies are required to enhance our understanding, and hence inform targeted interventions to curb TB transmission, particularly in high burden communities. This study aimed to explore the associations between TB transmission and socio-economic risk factors in one such high TB and HIV burdened community. Methods: A cross-sectional molecular epidemiology study was conducted among adult TB patients resident in a geographically well-defined peri-urban township of Cape Town between 2001 and 2010. Following informed consent, clinical and demographic data were extracted from TB registers and clinical folders. Additional socio-economic data were collected using interviewer-administered questionnaires that were designed to capture data on TB history, TB contacts, socio-economic conditions such as occupation, income level, educational level, sexual behaviour, sexual history in addition to other social and demographic data. M.tb isolates from TB patients were previously analysed using IS6110-based RFLP. Strains with <6 copies of IS6110 (low bandwidth strains) are known to be poorly differentiated and so were excluded from analysis. Composite variables were generated for the social and economic factors using a scoring algorithm to create a "social score" and an "economic score". Data was analysed using StataCorp version 12 software. Bivariate associations and adjusted binary logistic regression analyses were performed to determine associations between TB transmission and the social/economic score in addition to other risk factors that were studied. Results: Of the 509 participants who had complete data available, 352 (69%) were classified as clustered while the remaining 157 participants (31%) were classified as non-clustered. Our analysis showed that clustered cases were more likely to have stayed for a longer period in the study community, (OR=1.06, C.I: 1.02 to 1.10, p=0.006). Clustered cases were also more likely to have stayed in the same house for longer, (median=3 years vs. 2 years, p=0.06) and to live in more crowded conditions as shown by the size of the house and number of rooms used for sleeping (p=0.038). While the evidence was weak, there was a tendency towards a positive association between a high social score and clustering (OR=1.39, C.I: 0.94; 2.03, p=0.08). Conversely, there was a moderate negative association between a high economic score and clustering (OR=0.69, C.I: 0.45; 1.06, p=0.09). Conclusions: While the association between poverty (poor socio-economic status) and TB transmission is not new, the association between TB transmission and prolonged stay within a high burdened community that we report in this study is novel. Our findings further suggest that even in poorer communities there is a "sliding-scale of poverty", with individuals at the lower end of the economic scale being at greater risk for acquiring TB infection and that targeted interventions to address TB transmission in such high burdened communities may be required.

Abstract Background: Alcohol consumption in South Africa is a major contributing factor to the quadruple burden of disease. Additionally, South Africa has the highest rate of Foetal Alcohol Syndrome in the world. As effective interventions are available for hazardous and harmful drinking, screening for this behaviour in primary care can potentially contribute to improving health outcomes and reducing the cost to society. Existing validated screening questionnaires are available to identify those who drink at hazardous or harmful levels. However, no tools have been validated for women of childbearing age in South Africa. Any screening tools recommended for implementation should be as brief as possible with high sensitivity and specificity to justify the time spent on screening and minimise time spent on false positive results. Objectives: To identify the most appropriate existing abbreviated version of the Alcohol Use Disorder Identification Test (AUDIT) questionnaire for South African women aged 18-44 and determine whether adjustments are required for urban/rural residence or patterns of consumption (binge drinking vs non-binge drinking). Additionally, to determine whether a single question can be used to identify possible dependent drinking. Methods: An existing dataset was used for the analysis, collected by means of household surveys conducted in 2006 in rural areas of the Western Cape and urban areas in Gauteng, South Africa. The Western Cape sample was selected by stratified random sampling of farm workers and the Gauteng sample was selected by cluster random sampling. AUROC analysis was used to compare the abbreviated questionnaires (AUDIT-C, AUDIT-3, AUDIT-4, AUDIT-PC, AUDIT-QF), CAGE and single questions to results of the full AUDIT screening questionnaire as the gold standard. Data was stratified in relation to binge drinking and the analyses repeated to determine any effect of drinking patterns on the results. Results: AUDIT-4 and AUDIT-PC were the best performing brief questionnaires in both rural and urban settings. AUDIT-4 had AUCs of 97.52% and 96.87% in Western Cape and Gauteng respectively. AUDIT-PC had scores of 97.52% and 93.98% in Western Cape and Gauteng respectively. Stratification by drinking pattern did not substantially influence the results. The single question method of identification of possible dependent drinking is not supported by the results of this study, with AUCs of < 75%. Conclusion: AUDIT-4 appears to be the best brief questionnaire for the identification of hazardous and harmful drinking among women aged 18-44 in South Africa, with no adjustments required for urban/rural settings or drinking patterns.

The first 1000 days is recognised as the most sensitive period of development of an individual’s life. Infants in low and middle-income countries face significant risks to their development during this period. Research confirms that having a responsive, caring relationship between the infant and caregiver is a considerable protective factor for infants, and results in better longterm outcomes in cognition, language, academic achievement, social skills and behaviour. The aim of this review was to systematically examine the literature to identify interventions in low and middle-income settings that influence infant-caregiver responsivity and attachment and explore the characteristics of the interventions that contribute to its efficacy. Ten electronic databases were searched (Pubmed, Scopus, PsycINFO, PsycARTICLES, Africa-Wide, CINAHL, Health Source, ERIC, SocINDEX &amp; Cochrane Library), as well as hand searching relevant reference lists for published articles in the English language from 1969-2018. A total of 11 765 studies were identified through the search strategy and 24 studies were included in the review. The included studies were critically appraised and then coded descriptively to enable a narrative synthesis of findings. Studies were from low and middle-income countries in Africa, Asia, Europe and South America and consisted predominantly of randomized control trials, but also quasi-experimental studies and a single cohort and qualitative study were included. All but two studies found positive effects on responsivity, attachment or both. For ten of the studies this effect was significant. The findings suggest implementing individual or group interventions in LMICS has a positive effect on caregiver-infant relationships and can be delivered successfully by trained non-professional staff.

Includes bibliographical references (leaves 71-80). / The few studies on intimate femicide-suicide have mainly been conducted in developed countries. These studies have found that a disproportionate number of male partners commit suicide after killing their female partner. However, not much is known about intimate femicide-suicide in developing countries. The purpose of this study was to describe: the incidence and patterns of intimate femicide-suicide in South Africa and to compare the factors which distinguish intimate femicide-suicide from cases in which the perpetrator does not commit suicide. The study was designed as a retrospective national mortuary based study of all female homicides where the victim was aged 14 years and older for the year 1999. Data was collected from a stratified cluster sample of 25 mortuaries in South Africa. National incidence rates and factors associated with perpetrator suicide were derived by taking into account the stratification and weighting of mortuaries. This study found that 19.4% of intimate femicide perpetrators also commit suicide within a week of the murder. The estimated rates for intimate femicide-suicide were 1.7/100 000 women 14 years and older and 2.1/100 000 males 14 years and older. A logistic regression analysis to compare the factors which distinguish intimate femicide-suicide from cases in which the perpetrator does not commit suicide shows that perpetrator suicide were associated with: the perpetrator being of White race; employed as a professional or white collar worker; and owing a legal gun. The study findings have shown that South Africa has the highest reported rate for intimate femicide-suicide in the world. This poses an important public health problem. Unraveling the factors associated with perpetrator suicide after killing an intimate partner is complex. However, legal gun ownership plays a significant role in such killings. It is therefore imperative that access to guns be controlled and monitored.

Includes bibliographical references. / Highly active antiretroviral therapy (HAART) has dramatically affected the course of HIV disease, resulting in a significant reduction in AIDS-related morbidity and mortality in both developed and developing countries.

Includes bibliographical references. / The research undertaken for this MPH dissertation examines the effectiveness of SMS as an intervention to promote vaccination. Part A is the research protocol, which outlines the background and the process of this research. This study utilizes systematic review methods based on those of the Cochrane Collaboration to synthesize the best current evidence from articles archived in various bibliographic databases and clinical trial registers. Part B presents the entire research project in a format suitable for journal submission. The background of this research project is summarised and the results are presented and discussed.

Background: Despite a high burden of disease, in many health districts in the Wes tern Cape, South Africa, intimate partner violence is known to be poorly recognised and managed. To address this gap in service an innovative intersectoral model for the delivery of comprehensive intimate partner violence (IPV) care was piloted in the Witzenberg, a rural, agricultural sub - district known to have a high incidence of IPV. It was not known whether the initiative was a success from the perspective of the women using the service, from the service providers or from the managers. Methods: A qualitative evaluation was conducted. Ten service users were interviewed to explore their experience of the intervention. Two focus groups were conducted amongst health care workers, and one focus group and six interviews were conducted with the intersectoral implementation team, to understand their experience of implementing the intervention. Documents relating to the pilot were also analysed. A contextualized thematic content analysis approach was used, triangulating the various sources of data, and utilising inductive as well as deductive approaches. Results: Over the pilot period 75 women received the intervention. Study participants described their experience of it as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For health care workers, barriers to inquiry about intimate partner violence included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints impacted on the pilot, affecting continuity of care, privacy and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example high levels of alcohol misuse and socioeconomic disempowerment highlighted the need for a multifaceted approach to addressing intimate partner violence. Conclusion: The results of this qualitative evaluation draw attention to the need to take a health systems approach and focus on contextual factors when implementing complex interventions. They will be used to inform decisions about instituting appropriate intimate partner violence care in the rest of the province. Additionally, there is a pressing need for clear policies and guidelines framing intimate partner violence as a health issue.

Eliciting adverse event (AE) and non-study medication reports from clinical research participants is integral for evaluating drug safety. However, using different methods to question participants yields inconsistent results, compromising the interpretation, comparison and pooling of data across studies. This is particularly important given the widespread use of antimalarials in vulnerable populations, and their increasing use in healthy but at-risk individuals as preventive treatment or to reduce malaria transmission. Experienced, qualified antimalarial drug clinical researchers were invited to participate in a Delphi process, to facilitate consensus on what panellists consider to be optimal (relevant, important and feasible) methods, tools, and approaches for detecting participant-reported AE and non-study medication data in uncomplicated malaria treatment studies. This Delphi built on a previous survey conducted among malaria clinical researchers about different elicitation methods they used. The findings thereof, and a summary of relevant literature, were presented to Delphi panellists in round one after which they were asked to suggest further questioning methods or approaches that they considered as important and feasible for asking participants (or their caregivers) about their health to collect adverse events, and use of non-study medications to collect previous or concomitant medication data. In round two, the panellists were presented with the collated suggestions from round one to rate each type of question in terms of its relevance, importance and feasibility. Here, panellists would rate methods or approaches as either optimal or not optimal for inclusion in a 'menu' of harmonized or standard types of core questions to be used in a variety of uncomplicated antimalarial treatment studies. In round three, panellists were presented with a summary of items which had achieved consensus in round two and, for items that had not achieved consensus they were asked whether or not they wished to change their response in view of the group's overall response. Of the 72 invited, 25; 16 and 10 panellists responded to the first, second and third rounds of the Delphi process respectively. Overall, 68% of all questioning items presented for rating achieved consensus. When asking general questions about health, panellists agreed to include a question/concept about any change in health, taking care to ensure that such questions/concepts do not imply causality. Eighty-nine percent (39/44) of structured items about specific signs and symptoms, were rated as optimal. For non-study medications, a general question and most structured questioning items were considered an optimal approach. The use of mobile phones, patient diaries, rating scales as well as openly engaging with participants to discuss concerns were also considered optimal complementary data-elicitation tools. This study succeeded in reaching consensus within a section of the antimalarial drug clinical research community about using a general question concept, and some structured questions for eliciting data about AEs and non-study medication reports. The findings suggest that one method of questioning may not be superior to another, or sufficient to fulfil its purpose on its own and that the use of a combination of methods may be optimal. As malaria clinical research is often conducted in children (and other vulnerable groups), this becomes an important consideration in the design of appropriate elicitation methods cognisant of any particular factors that may impede accurate reporting in these groups. The concepts and items found in this Delphi survey to be relevant, important and feasible should be further investigated for potential inclusion in a harmonised approach to collect participant-elicited antimalarial drug safety data. This, in turn, should improve understanding of antimalarial drug safety.